The Silent Killer: The Effort Toward Global Elimination of Maternal and Neonatal Tetanus

| February 1, 2012 | 0 Comments

By Frederic Hua

Clostridium tetani, the bacterium responsible for tetanus, is ubiquitous, yet its effects are found to be most devastating in developing countries. The World Health Organization (WHO) estimated in 2008 that 59,000 newborns die from tetanus every year. Termed “maternal and neonatal tetanus” (MNT), the condition is generally caused by lack of proper vaccination in conjunction with unhygienic delivery practices. In neonates, this is particularly precarious as the detachment of the umbilical cord provides a readily available breach for C. tetani infiltration.

In the developed world, tetanus has been eliminated almost exclusively via well-established post-natal care services. However, achieving elimination in such a manner has proven to be more difficult in the developing world. As a result, recent efforts for worldwide elimination are driven firstly by extensive administration of the tetanus toxoid (TT) vaccine, followed by establishment of health programs promoting clean delivery practices. Tetanus presents itself uniquely worthy of attention as an issue in which significant progress has been made despite being incapable of true eradication.

Infant suffering from neonatal tetanus ( Courtesy of Martha H. Roper)

The first system towards global elimination of MNT was developed during the 1989 World Health Assembly. Elimination was characterized as 1 case of tetanus per 1000 live births, with a deadline in 1995. Districts at risk were identified and strategies for combating MNT were drafted with governmental collaboration. For countries with moderately developed health services, achieving MNT elimination was relatively simple—women who became pregnant were administered TT and taught clean delivery practices. However, the highest burden of MNT was found to be in hard-to-reach rural areas, where there is underdeveloped health infrastructure and a prevalence of unhygienic post-delivery practices.

This prompted the development of the supplementary high-risk approach. With this continuing approach, a series of campaigns are conducted into selected high-risk areas, and all women of childbearing age (15-45 years) are vaccinated with three doses of TT. Campaigns are followed with educational programs designed specific to the communities, emphasizing proper cord-care and clean delivery along with the establishment of routine perinatal services. Without substantial external funding however, 1995 came to pass with global elimination unrealized.

The effort was launched again in 2000 by the WHO, UNFPA, and UNICEF, targeting the 58 countries in which MNT still existed as a public health issue and with a goal set at elimination by 2005. The estimated cost was $1.20 for each woman, including vaccines, operational costs, and promotion of clean deliveries. Despite the apparent cost effectiveness, the total expenditure over the intended 5 years was expected to amount to $130 million.

Vaccination protects women of child-bearing age from tetanus and provides passive immunity to their children. (Courtesy of Martha H. Roper)

Also in 2000, The GAVI Alliance was established in order to provide proper funding and vaccines for eligible countries, with support from the International Finance Facility for Immunisation (IFFIm). In order to ensure commitment to health programs, countries must also contribute financially to the initiatives. Although the 5 year goal was unable to be reached, significant accomplishments were able to be made. By 2007, more than 70 million additional women were administered vaccines, and 10 countries had declared the elimination of MNT. The effort is still firmly active, with several organizations now onboard including Proctor & Gamble, JICA, the Gates Foundation, and Kiwanis.

Dr. Walter Orenstein, assistant professor at the Emory University School of Medicine, director of the Emory Program for Vaccine Policy and Development, and former director of the National Immunization Program at the CDC, explains the exhaustive efforts needed to tackle tetanus: “The problem is with elimination and not eradication. What you have is a reservoir in the environment, and hence you can never stop immunizing. This is different than smallpox, different than what we’re hoping for polio, and different than measles. You can’t eradicate tetanus. You always have to be aware and you have to keep immunization coverage up.”

This brings up the concept of maintenance, which is of equal if not greater importance than elimination. Dr. Orenstein states: “To the extent we can deliver all of these doses, it would be great, but it’s something that has to be done day in and day out—which means investment on the part of the countries themselves in building and maintaining these systems.” It is essential that there is proper coordination with agencies in all levels of state for effective management and continuance of health programs. “You really need to have good surveillance. Surveillance has to be done with national or district level government. WHO and UNICEF provide technical guidance and consultative support, but they do it under government authority.”

More recently, Uganda announced successful elimination of MNT, with several countries awaiting their own validations. The current status of the elimination is unclear because elimination can only be declared after a latency period. Since the first big launch in 1989 towards MNT elimination, however, neonatal deaths due to tetanus have dropped remarkably; from nearly 800,000 a year to a few tens of thousands. Nevertheless, a continuing effort on parts of both government and organizations alike is necessary for completing the elimination project and maintaining it for future generations.

Category: Panorama, Spring 2011, Women and Children

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